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4 ENVIRONMENTAL HEALTH DIVISION APPLICATION FOR UNDERt M TANK RETROFIT, OR PIPING REPAIR PERMIT THIS PERMIT EXPIRES 90 DAYS FROM THE APPROVAL DATE. DO NOT WRITE IN ANY SHADED AREAS. INDICATE PERMIT TYPE BELOW: _TANK RETROFIT PIPING REPAIR w AJ NE 415�1 JLtj, I jq& I - 17,3 7 BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. nn NamECA2L JF^o"aC?."ra^-' address F/l Nu phone number -62--.1) 1'lW-173! Signature EH 23-0038 sf� 7s t 01'L." qA opT 1 EPA SITE # I PROJECT CONTACT & TELEPHONE # r / / ��c�ITPHONE A' FACILITY NAME c�EL� #/22- 93/- 347,E t C DRESS S GJ AVER—L-0-0 I3 I L I CROSS STREET (� Q I/ Y I I 7 1 i OWNER/OPERATOR I� L� I PHONE # �iS� K �( `1 - /7 H C CONTRACTOR NAME PHONE #/lam• L L S �2J c,E D N I CONTRACTOR ADDRESS SZ % /y - ,4�kV 1 w CA LIC # �O(� Q QZ CLASS T R I INSURER I WORK.COMP.# A C I OTHER _NFORMATDJN I T 0 I I PHONE # R PHONE # TANK ID # C 0'7) TANK SIZE CHEMICdLS STOREDCUURRRENTLY/PREVIOUSL'i DATE UST STALLED ' T �� 39- A 39 - N 39- K 39- 9- 39 -P 39- P1 LI 39- X APPROVED APPROVED WITH CONDITIONS) DISA-PPROVED A ' lye (SEE ATTACHMENT WITH CONDITIONS) J p N' PLAN REVIEWERS NAME �'/j f '/ y� �!� DATE APPLICANT MUST PERFORM ALL WORK IN ACCORDANCE WITH SAN JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES. OWNER OR LICENSED AGENT'S SIGNATURE CERTIFIES THE FOLLOWING: "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL NOT EMPLOY ANY PERSON IN SUCH A MANNER AS TO BECOME SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." CONTRACTOR'S HIRING OR SUBCONTRACTING SIGNATURE CERTIFIES THE FOLLOWING:I "I CERTIFY THAT IN THE PERFORMANCE OF THE WORK FOR WHICH THIS PERMIT IS ISSUED, I SHALL EMPLOY PERSONS SUBJECT TO WORKER'S COMPENSATION LAWS OF CALIFORNIA." � � � TITLE 6E2"V1'Z11C 7'�5L4 DATE Z - 7- 01/ APPLICANT'S SIGNATURE:I BILLING INFORMATION: Indicate the responsible party to be billed for additional PHS-EHD staff time expended beyond permit payment coverage per tank. If the party designated below is different than the permit applicant, e.g. property owner, the party must acknowledge this responsibility for the billing by signature and date below. nn NamECA2L JF^o"aC?."ra^-' address F/l Nu phone number -62--.1) 1'lW-173! Signature EH 23-0038 sf� 7s t 01'L." qA opT 1